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Table of Contents
MUSINGS
Year : 2020  |  Volume : 3  |  Issue : 5  |  Page : 115-118

Management of cancer during the COVID-19 pandemic: Practical suggestions for the radiation oncology departments


Department of Radiation Oncology, Manipal Hospitals, Dwarka, New Delhi, India

Date of Submission03-Apr-2020
Date of Decision06-Apr-2020
Date of Acceptance08-Apr-2020
Date of Web Publication25-Apr-2020

Correspondence Address:
Anusheel Munshi
Department of Radiation Oncology, Manipal Hospitals, Dwarka, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_111_20

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How to cite this article:
Munshi A, Rastogi K. Management of cancer during the COVID-19 pandemic: Practical suggestions for the radiation oncology departments. Cancer Res Stat Treat 2020;3, Suppl S1:115-8

How to cite this URL:
Munshi A, Rastogi K. Management of cancer during the COVID-19 pandemic: Practical suggestions for the radiation oncology departments. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Jun 1];3, Suppl S1:115-8. Available from: http://www.crstonline.com/text.asp?2020/3/5/115/283285



On December 31, 2019, the World Health Organization (WHO) China Country Office was informed about the cases of pneumonia of unknown etiology detected in Wuhan City, in the Hubei Province of China. The cause was soon determined to be the novel coronavirus (SARS-CoV-2). On March 11, 2020, the WHO declared COVID-19 as a global pandemic, which rapidly crossed borders and led to a major health-care crisis and economic slowdown. The crisis has brought the world to a near-complete standstill. As of April 1, 2020, 750,890 confirmed cases of COVID-19 were reported globally, with a total of 36,405 deaths. Most international health organizations have expressed an urgent need to stop, control, and reduce the impact of the virus at every opportunity.[1]

Although radiation oncologists are not on the front line for fighting COVID-19, the current pandemic has given rise to some challenging issues pertaining to radiotherapy facilities. The present situation has resulted in an urgent need to share technical expertise for the radiotherapy departments. The issues are multifaceted, but are primarily related to treatment, equipment, and safety of the departmental staff as well as the patients and their attendants when ensuring that oncological outcomes are not compromised. Prioritizing radiotherapy treatments when delaying or avoiding all nonessential procedures or outpatient department (OPD) visits is of utmost importance in the present scenario. Simultaneously, the patients must be categorized into risk groups, depending on the type of malignancy, comorbidities, and urgency of treatment, to reduce their risk of acquiring the infection. It is also crucial to reevaluate the radiotherapy dose fractionation schedules and implement them whenever feasible. [Table 1] gives the details of the precautions that must be taken in specific areas of the department.
Table 1: Suggested precautions/check points in various areas in the department of radiation oncology

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  Outpatient Department Area Top


Routine OPD work should be minimized to the bare essential to ensure safety of the patients and health-care workers. Follow-up or non-emergency visits may be avoided by providing telephonic or video consultation.[2] All patients coming to the OPD must get their travel history, temperature, and other vitals recorded at the nursing stationfirst. For the doctors, it is advisable to make a note of all the past prescriptions and reports of the patients. Once the details are recorded, the patient (with only one attendant) should be brought into the consultation room. The consultation rooms must be well ventilated, and the door can be left open during consultations. It is also advisable for the doctors to maintain a safe distance of at least five feet from the patient and attendant. Local examination, especially that of the oral cavity, and the per vaginal and per rectal examinations, should not be done without adequate protective gear and washing/sanitizing the hands as per the WHO recommendations.[3],[4] One needs to properly inform the patients about the ongoing pandemic and the risk of cross-infection during hospital visits.


  Selection of Patients Prior to Starting Radiotherapy Top


As per the guidelines from the National Institute for Health and Care Excellence, patients should be treated with radiotherapy only if it is “unavoidable,” and even then, the “shortest safe form of treatment” should be used.[5]

Patient selection is one of the most critical aspects for radiation oncologists. The radiation oncologist should duly triage the patients that have been referred for radiotherapy into three broad categories as follows:

  • High priority: This group of patients needs an urgent commencement of radiotherapy. This includes cases of brain metastasis, severe and painful bone metastasis, superior vena cava obstruction not likely to respond to chemotherapy, and hemostatic radiotherapy where other measures have failed
  • Intermediate priority: This group comprises patients who are due for radiotherapy, but it can be delayed for 1–3 weeks. It includes patients who are to receive adjuvant therapy for breast carcinomas, postoperative patients with head and neck and gynecological malignancies, and patients with oligometastasis for potentially radical treatment
  • Low priority: This group includes patients with equivocal benefit of radiotherapy (as per existing guidelines) and patients with prostate cancer (who can be kept on hormonal therapy).


The high-priority patients need to be started on radiotherapy, with due counseling, on an urgent basis. Intermediate-priority patients should be counseled regarding starting radiotherapy immediately versus deferring it for 1–3 weeks. Low-priority patients should be counseled to revisit the OPD after 1–2 months for starting radiotherapy.

All the patients taken for radiotherapy must be counseled in detail about the ongoing pandemic, the risk of cross-infection, and the likelihood of interruptions during the course of radiotherapy. A special written consent to this effect should also be taken.


  Radiation Oncology Department Top


It is critical to ensure the safety of the departmental personnel. Provision of sanitizers at multiple areas in the department, counseling of the staff to take adequate precautions when handling patients, use of personal protective equipment (masks, gloves, and scrubs), and practicing meticulous hand hygiene are some of the measures. Patients and attendants coming for treatment should be advised to wash their hands upon entering the department. They should then be screened by the department nurse. Seating within the department should be planned in a way that patients are six feet away from each other. All magazines, brochures, toys, and other recreational materials should be removed from the waiting area to reduce the source of cross-contamination.

The entire department can be sectioned into clean, semi-clean, and contaminated areas. The clean areas could include places with no entry to the patients, such as the departmental offices and treatment planning room. The semi-clean areas could include the reception area. The contaminated areas could include the patient waiting area, mould room, examination room, nursing area, and linear accelerator (LINAC) area. The degree of precautions and protection should increase as per the risk of the respective area. Medical-grade alcohol (75%) should be used to clean relevant items and objects (tables, chairs, doorknobs, etc.). For floors and other areas, 2000 mg/L disinfectant is recommended.[6],[7]

It is also advisable to make a duty roster so that all departmental personnel can report on an alternating schedule (other options are 3 days on/off or weekly on/off) instead of a daily schedule, thus judiciously using the staff and minimizing exposure. Pragmatic scheduling of patients for daily radiotherapy will ensure less clustering in the waiting area.


  Simulation/treatment Planning Top


Use of devices that require placement of the mouthpiece for 4D radiotherapy should be limited only to patients for whom it is strongly recommended (young, left breast). In general, 4D techniques take considerable time during all phases of treatment (simulation, planning, and delivery) and should be used only if they are very strongly indicated. Use of hypofractionated regimens for patients should be strongly considered wherever applicable. This reduces patient visits to the department, simultaneously decreasing the load on the health-care facility. It is advisable that the complexity of radiotherapy planning (and treatment) be reduced wherever possible to ease the pressure on the departmental workforce. Treatment plans with lesser monitor units are preferable. [Table 2] gives a list of sites and their suggested hypofractionated regimens.[8],[9]
Table 2: Hypofractionated regimens for different body sites

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  Linear Accelerator Area Top


The LINAC area is an enclosed area, with no windows or cross-ventilation, and has a greater risk of harboring infections than other areas. Technologists are the staff who need to be most careful when dealing with patients. They need to ensure the regular cleaning of the couch and changing of sheets after every patient's treatment. It is also advisable to schedule beam delivery in the best possible sequence (to minimize the on-couch time). It is preferable to keep separate time slots for outpatients and inpatients. In busy centers, separate time slots for different sites of the body can also be considered. Some articles have recommended the use of ultraviolet irradiation (at 2-m distance) for sterilization of the LINAC area (every 2 h for 15–30 min, shutting down the central ventilation during that time).[10] Fumigation of the LINAC area with quaternary ammonium compounds can be considered at periodic intervals (ensuring that the machine and the couch areas are appropriately covered during the fumigation process).


  Older Patients or Patients With Comorbidities Top


Older people and people with pre-existing medical conditions, such as asthma, diabetes, and heart disease, appear to be more vulnerable to becoming severely ill because of the virus.[11],[12] Hence, additional care should be taken when simulating these cases. Patients with cancers of slow/indolent biology, such as prostate cancer, can be continued on hormonal therapy till the end of the pandemic.

Palliative cases

Use of single-fraction treatments, especially in patients with bone metastasis or patients requiring hemostatic radiotherapy, should be strongly considered.

In times to come, it is inevitable that patients with cancer will present with symptoms of COVID-19 (or will test positive for COVID-19), which will mandate taking measures such as decision to continue or withhold cancer treatment, stratification of patients into low- and high-risk groups, and dealing with infected patients who need cancer treatment when protecting the departmental staff.[13]

To conclude, in the absence of any firm international guidelines for the management of radiotherapy patients, we have attempted to highlight the issues encountered in a radiotherapy facility in view of the ongoing COVID-19 pandemic and made some practical suggestions to resolve the same.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019. [Last accessed on 2020 Apr 03].  Back to cited text no. 1
    
2.
Mathew AS, Agarwal JP, Munshi A, Laskar SG, Pramesh CS, Karimundackal G, et al. A prospective study of telephonic contact and subsequent physical follow-up of radically treated lung cancer patients. Indian J Cancer 2017;54:241-52.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Available from: https://apps.who.int/iris/handle/10665/331495. License: CCBY-NC-SAGoogleScholar. [Last accessed on 2020 Mar 19].  Back to cited text no. 3
    
4.
Available from: https://apps.who.int/iris/handle/10665/331495. License: CCBY-NC-SAGoogleScholar. [Last accessed on 2020 Apr 03].  Back to cited text no. 4
    
5.
National Institute for Health and Care Excellence. Covid-19 Rapid Guideline: Delivery of Radiotherapy. NICE Guideline [NG162]; March, 2020. Available from: https://www.nice.org.uk/guidance/NG162. [Last accessed on 2020 Apr 03].  Back to cited text no. 5
    
6.
Available from: https://www.elekta.com/. [Last accessed on 2020 Apr 03].  Back to cited text no. 6
    
7.
Available from: https://www.varian.com/about-varian/covid-19. [Last accessed on 2020 Apr 03].  Back to cited text no. 7
    
8.
Available from: https://www.rcr.ac.uk. [Last accessed on 2020 Apr 03].  Back to cited text no. 8
    
9.
Munshi A, Krishnatry R, Banerjee S, Agarwal JP. Stereotactic conformal radiotherapy in non-small cell lung cancer – An overview. Clin Oncol (R Coll Radiol) 2012;24:556-68.  Back to cited text no. 9
    
10.
Available from: https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines-H.pdf. [Last accessed on 2020 Apr 03].  Back to cited text no. 10
    
11.
Wang T, Du Z, Zhu F, Cao Z, An Y, Gao Y, et al. Comorbidities and multi-organ injuries in the treatment of COVID-19. Lancet 2020;395:e52.  Back to cited text no. 11
    
12.
Guan WJ, Liang WH, Zhao Y, Liang HR, Chen ZS, Li YM, et al. Comorbidity and its impact on 1590 patients with Covid-19 in China: A Nationwide Analysis. Eur Respir J 2020. pii: 2000547.  Back to cited text no. 12
    
13.
Filippi AR, Russi E, Magrini SM, Corvò R. COVID-19 outbreak in Northern Italy: First practical indications for radiotherapy departments. Int J Radiat Oncol Biol Phys 2020. pii: S0360-3016(20)30930-5.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2]



 

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